British Journal of Radiology (2006) 79, e8-e11
© 2006 British Institute of Radiology
doi: 10.1259/bjr/56199075
Complete eversion and prolapse of bladder concurrent with primary adenocarcinoma
Y H Kim, MD1,
D J Sung, MD, PhD1,
S B Cho, MD1,
K B Chung, MD1,
S H Cha, MD1,
H S Park, MD2 and
J W Um, MD3
Departments of 1Radiology 2Urology and 3Surgery, Korea University College of Medicine, Anam Hospital, Korea University, College of Medicine, #126-1, 5-Ka Anam-dong, Sungbuk ku, Seoul 136-705, Korea
Correspondence: Deuk Jae Sung, Department of Radiology, Anam Hospital, Korea University, College of Medicine, #126-1, 5-Ka Anam-dong, Sungbuk ku, Seoul 136-705, Korea.
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Abstract
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Complete eversion and prolapse of the urinary bladder is extremely rare. To the best of our knowledge, the imaging findings of complete bladder eversion have not been documented in the literature. Here, we report a case of complete eversion and prolapse of the urinary bladder demonstrated on MRI. Concurrent primary adenocarcinoma was found in the thickened wall of the everted urinary bladder.
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Case report
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A 78-year-old female, gravida 10, para 8, presented with a 10-year history of a recurrent protruding mass, which was reduced by herself, in the genital area. On admission to the hospital, she complained of an irreducible mass in the genital area for 1 month. She had a long history of stress urinary incontinence and had suffered from total incontinence during the preceding 2 years. She did not sustain a pelvic injury induced by a trauma or a complicated delivery. The physical examination revealed an erythematous mass, which was covered with whitish plaque at the apex of the mass, in the external genital area and a small orifice below the mass. Usual urethral orifice and vaginal introitus were not found in the external genital area.
Before undergoing MRI, sterile saline was infused into the small orifice below the mass through a catheter to demonstrate either the urinary bladder or the vagina and a possible fistula. MRI revealed a protruding mass in the external genital area without any evidence of a detectable bladder in the pelvis. The mass showed heterogeneous signal intensity and stretched both ureters inferiorly on T2 weighted image (Figure 1a,b
). The periphery of the mass was enhanced diffusely after administering the gadolinium contrast (Figure 1c). The uterus, distended by saline, descended so that it lay posterior to the pubis, but the cervix did not prolapse through the vagina (Figure 1a). Careful physical examination was performed again and two orifices were found bilaterally at the base of the mass (Figure 2). 5 Fr ureteral catheters were introduced into the orifices and the subsequent tubography showed stretched ureters below the symphysis pubis with bilateral hydronephroureterosis, which was demonstrated on the MR images (Figure 3). The genital mass was confirmed as an everted and prolapsed urinary bladder with the ureteral orifices being exposed externally. The periphery of the mass, which showed diffuse contrast enhancement, was the thickened wall of the everted bladder.
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Figure 2. Colour photograph shows an erythematous mass covered with whitish plaques in the external genital area. Two orifices(arrows), which were confirmed as ureteral orifices, are exposed externally at the base of the mass with 5 Fr ureteral catheters.
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Figure 3. Tubography through the ureteral catheters shows stretched ureters below the symphysis pubis with bilateral hydronephroureterosis.
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Even though the MRI did not demonstrate a focal mass lesion in the everted bladder, multiple punch biopsies were performed to rule out a potential malignancy because the everted bladder wall, which corresponded to the periphery of the mass, was diffusely thickened with contrast enhancement on the MR images. Histological examination revealed adenocarcinoma with moderate differentiation.
Radical cystectomy and urinary diversion were performed. Gross examination showed a diffusely thickened and everted bladder wall peripherally with omental fat centrally. The tumour revealed a diffuse infiltrative pattern in the thickened wall (Figure 4). Further pathological evaluation confirmed the diagnosis of mucinous adenocarcinoma in the everted bladder.
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Figure 4. Colour photograph of the gross surgical specimen shows a large mass partially covered by everted and thickened bladder wall(arrows). The central portion of the mass is herniated omental fat ( ). The tumour (curved arrows) reveals a diffuse infiltrative pattern in the thickened wall.
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Discussion
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A MEDLINE search from 1966 to December 1999 revealed only nine prior cases of bladder eversion and all cases were reported in female patients. The diagnosis of prolapse in female patients usually refers to genital prolapse, i.e. uterine or vaginal. The lower urinary tract organs, including the bladder, urethra and ureter can also prolapse. Complete eversion and prolapse of the urinary bladder must be differentiated from urethral prolapse, prolapse of an ureterocele, prolapse of redundant bladder mucosa, or a polypoid tumour of the urethra [1].
The pathophysiology of bladder eversion remains speculative because of the extreme paucity of information. Half of the previously reported cases of bladder eversion had concurrent uterovaginal prolapse, which might predispose the patient to bladder eversion by two mechanisms: (1) widening of the urogenital hiatus can result in pulling the bladder base and posterior urethra away from the pubic bone, which can open the proximal urethra and allow the bladder to begin inverting; (2) vaginal prolapse can cause obstructed voiding with straining, which can also begin the process of the bladder inverting through the urethra [2]. However, our case did not show the concurrent uterovaginal prolapse. The inordinate laxity of the bladder outlet and urethra is assumed to be the other underlying mechanism [3].
Complete eversion and prolapse of the urinary bladder can cause bilateral hydronephrosis and resultant azotemia. Possible mechanisms for hydroenphrosis in patients with a prolapsed bladder include bladder outlet obstruction, ureteral kinking and stretching by the prolapsed bladder [4]. Our case presented with bilateral hydronephrosis that resulted from the stretched ureters.
In the case of a prolapsed bladder, the posterior wall of the bladder descends along an arc, initially moving posteriorly and inferiorly to deform the anterior wall of the vagina and then bulging forward as it exits the introitus, at MRI [5]. However, our case presented with a protruding mass at the vulva without any evidence of a detectable bladder in the pelvis at MRI and excluded the possibility of a cystocele.
MRI can show a bulging mass outside the external genitalia in complete eversion of the vaginal vault. The presence or absence of uterovaginal prolapse should be noted in the complete eversion and prolapse of the bladder. Prior reports of transurethral bladder eversion described repair by either an abdominal or vaginal surgical approach. Vaginal obliteration or reconstruction combined with a sling urethropexy can be sufficient to address primary pelvic floor defects in patients with transurethral bladder eversion [2]. Pelvic visceral prolapse frequently involves multiple sites, which is suggestive of global pelvic floor weakness. MRI can clearly show pelvic visceral prolapse and be a useful pre-operative planning tool in women with multicompartment involvement of pelvic floor weakness for whom a complex repair is planned or who have undergone previous repairs.
Adenocarcinoma is the third most frequent malignancy of the bladder and has been reported to represent 0.5–2% of all bladder cancers. Primary non-urachal adenocarcinomas of the bladder usually develop in patients with diffuse intestinalization of the bladder mucosa associated with obstruction, cystocele, non-functioning bladder, or chronic irritation. They are believed to develop from metaplasia of the bladder epithelium and are associated with cystitis glandularis [6]. The concurrent mucinous adenocarcinoma in our case was assumed to originate from the chronic irritation on the everted bladder wall. The mucosa can become thick if the vaginal vault prolapse is long-standing [7]. As our case demonstrated, the wall of the chronically everted and prolapsed bladder was thick. A diffusely thickened bladder wall with stranding in the surrounding fat is a frequent imaging finding of primary bladder adenocarcinoma [8]. Our case showed diffuse thickening of the everted bladder wall with heterogeneous contrast enhancement on contrast-enhanced MR images. Even though a variety of inflammatory, infective and fibrotic conditions can also result in diffuse bladder wall thickening, it is important for a radiologist to consider adenocarcinoma in the differential diagnosis [8].
In conclusion, the differential diagnosis must include complete eversion and prolapse of the urinary bladder when the diagnostic imaging reveals a protruding mass at the vulva without evidence of a detectable bladder in the pelvis. The bladder eversion can only develop in female patients with or without genital prolapse. MRI is useful in the assessment of the urogenital prolapse and its associated abnormalities.
Received for publication January 14, 2005.
Revision received April 23, 2005.
Accepted for publication June 27, 2005.
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References
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Abstract
Case report
